Monthly Archives: November 2018

Do College Students Get Enough (Nutrients) to Eat?

Thanksgiving week is often the first time parents get to see their college-age children after they leave for the fall semester. They often come home not just with a knapsack filled with dirty laundry and a serious sleep deficit, but with the possible beginnings of nutrient deficiencies. It is unlikely that the student will have symptoms of scurvy (Vitamin C deficiency) or iron-deficiency anemia. But, at the very least, many will have been following a nutritionally questionable diet.

Worried about the eating habits of a young relative who is completing his first semester as a freshman, I queried him about the nutritional adequacy of the foods provided in his college’s dining room. The food was acceptable, I was told, although since he was a vegetarian, he couldn’t comment on the meat dishes. His problem, common to so many, was a schedule that included long afternoons in a physics or computer laboratory causing him to emerge for supper  after the dining room had closed. Then his only options were sandwiches and fries at the college-owned café that was open much later, or pizza from a place down the street.

But he mentioned that his friends teased him about his food choices because when he did eat in the dining room, he always had a salad and fruit (his mother would be proud). Asked what his friends usually ate, he quickly tossed out,  “Mac and cheese, pizza, hamburgers, onion rings, and soda. They eat terribly. They never eat vegetables or fruit.”  Knowing that he rarely drank milk and ate yogurt infrequently, I was happy to know that his calcium needs were being supplied by the chocolate milk he drank after long runs.

His perception about the  poor food choices of his friends has been confirmed by many studies of the food habits of college students. The reasons are pretty obvious. Breakfast is often skipped in favor of sleep, and often lunch and dinner may be obtained from food trucks, nearby pizza shops, fast-food restaurants, and snack shops rather than the college dining room. This is particularly true if meal tickets can be used at food trucks, coffee shops and other nearby restaurants.  One consequence, however, is a minimal consumption of fruits, vegetables, and often dairy products. Dieting, especially following  diets  that arbitrary eliminate various food groups (i.e. paleo, keto, cleanses), may also cause inadequate nutrient intake, although this is hardly confined to college campuses.

As the article by Abraham, Noriega and Shin point out (“College students eating habits and knowledge of nutritional requirements,” Survey of attitudes and eating habits  Abraham S, Noriega B, Shin J, J of Nutrition and Human Health 2018 ; 2:13-17), college students often know very little about their nutrient requirements, believe that food additives rather than high calorie content is the reason fast foods should be avoided, and either disregard or know very little about the relationship of nutrient intake to health.

Alerting this population to the consequences of inadequate nutrient intake is a mission that must wait its turn behind education on the perils of nicotine, excessive alcohol and unprotected sex. Not surprisingly, it is a subject rarely discussed, except perhaps by coaches who realize the importance of adequate nutrient intake for their players.  (“Web-based nutrition education for college students: Is it feasible?” Cousineau T, Franko D, Ciccazzo M, et al Eval Program Plann. 2006; 29: 23-33) Male college students, according to the article by Cousineau, Frano, Ciccazzo et al, are particularly uninformed about what they should or should not be eating. But all college students seem to know little about food labels, appropriate number of servings from various food groups, the relationship between calorie intake and energy metabolism, the need for fiber, vitamins and mineral rich foods, and indeed, what happens to food after it is ingested.

One wonders if the ready acceptance of misinformation about diets, effects of certain foods on cognition, inflammation, the intestinal tract, mood, and energy is not a consequence of college age and older adults knowing so little about basic physiology. Often the nutritional information is about as accurate as the belief that the world is flat. Yet where and when does the college student, and indeed anyone in the population, obtain some basic facts about how the body uses what is being consumed?

Weight gain is common in college, especially during the first year, due to a combination of lack of exercise, stress, too little sleep, and perhaps too much pizza and beer. Students are especially vulnerable to this when midterms and final exams approach. Somehow the message that good nutrition and adequate sleep might help cognition and mental performance, has not been able to offset the constant snacking and staying up all night that characterize these periods of intense study.

A simple solution to possible inadequate nutrient intake is a daily vitamin supplement or a vitamin supplement that also contains calcium and iron for those who avoid dairy products and foods rich in iron (such as red meat.) The vitamin supplement is, of course, no substitute for those fruits and vegetables, and dairy products the college attender should be eating. But until that happens, a chewable vitamin or a pill may be the best solution.

The Guest with the Surgically Shrunk Stomach & Thanksgiving Dinner

Surgical interventions to reduce the size of the stomach are increasing in popularity, predominantly because they have been successful in reversing years of dieting failures. Patients who have had these procedures, however, may find themselves struggling to deal with the excessive amounts of food commonly served on Thanksgiving.  Although Thanksgiving is still a day when we pause in our daily lives to be grateful for what we have, including food, health, family and friends, the holiday sometimes seems to be almost exclusively concerned with only the food. Judging by the number of media articles and television shows advising us on recipes and methods of cooking, sometimes it seems that the purpose of the holiday is to see how successful we are in preparing the meal.

The amount of food served on Thanksgiving Day must resemble a feast. If the host decides that the turkey, two vegetables and just one dessert are sufficient, he or she will be regarded as a food miser. “What are you making for Thanksgiving?” is the greeting of the week before turkey day, and guests often arrive with dishes to supplement the many made by the host. One young woman who is hosting Thanksgiving dinner for the family for the first time was gently reminded that her dinner plates were not sufficiently large to contain all the side dishes she thought she had to prepare.

The typical guest, confronted with all that food, manages to eat much more than the amount he or she would normally consume at a dinner meal.  Despite protestations of feeling too stuffed to eat another bite after the main course has been consumed, most will manage somehow to sample at least a couple of pies when dessert is served.

But what if the guest does not have considerable room in his or her stomach to eat the many dishes being offered? What if the guest has had bariatric surgery to reduce the size of the stomach, and now it can hold no more than a couple of ounces of food at one time? The point of the surgery is to make the stomach so small that the patient, eating only tiny amounts of food, will lose weight.

What makes an occasion like Thanksgiving so difficult for those who have had this surgery is that for years, they were able to eat whatever they wanted, and as much as they wanted. Even though they know it is physically impossible now for them to do so, emotionally this may be hard to accept.  I wonder if any one us who has not had such an operation can imagine how difficult it must be to watch others around the Thanksgiving table help themselves to large portions, take additional servings and eat as many desserts as are available. The guest with the surgically reduced stomach not only is unable to eat normal-size portions but must also restrict what is eaten to the foods that will nourish his body rather the foods that he may crave. Filling up on stuffing or marshmallow-topped sweet potato pie or onions in cream sauce is not an option when his body needs lean protein.  A normal size stomach can handle the turkey and all the side dishes; a surgically reduced stomach may accept only the turkey.

Moreover, those who have had this type of surgery may be reluctant to share this information with others at the table.  But then, how to explain the sudden significant decrease in food intake? Several years ago, I noted that a relative who was known for consuming large quantities of food was eating tiny portions, and refusing most of the dishes offered to him. When I asked him if he was not feeling well, he told me about this surgery to reduce the size of his stomach. Suddenly others, overhearing our conversation, threw questions at him so quickly he couldn’t answer them: What was the surgical procedure? Did it hurt? How much weight have you lost so far? What can you eat? Are you hungry? Even though it is no one’s business and the guest should not feel obliged to answer the questions, often, especially when relatives are present, people want their curiosity satisfied.

Fortunately for our guest with the surgically smaller stomach, there are probably others who are also limiting their food intake.  Many Thanksgiving dinners will have guests who are avoiding gluten, dairy, meat, all animal products, all carbohydrates, foods without probiotics, cooked foods, certain fruits and vegetables, fat, and salt. Thus several of the diners may be putting only one or two items on their plate, and in some cases guests may even bring their own food because they don’t want to risk eating foods which may make them ill.

But even if the limited food intake due to bariatric surgery is camouflaged by the presence of others who pick, choose, and reject the food being served, the psychological difficulty of not being able to eat freely remains. Portion control is essential as is eating slowly, limiting fluid intake including alcohol so the stomach has room for food, and knowing when to stop eating. This is not easy, and often is accompanied by a sense of loss as acute as that experienced by others…such as a diabetic or someone with certain types of gastrointestinal disorders who must accept that they can no longer eat everything they want.

Perhaps the presence of some guests who cannot indulge in unlimited eating might be a catalyst to decrease the excesses of the Thanksgiving meal. Certainly, one point of the meal is to be thankful that we can feed our families, friends, indeed, those in our community.  But feeding one’s guests and feeding them to excess are not the same thing.  If we simplify the menu, provide a realistic amount of food, and alter the emphasis from what is on the table to who is around the table, then even those who cannot eat much will not feel deprived.

Might Physical Activity Be as Effective as Antidepressants?

The well-known recommendation to exercise in order to relieve and/or improve a wide variety of health problems may sometimes seem exaggerated. One might ask whether going to the gym or chopping wood will truly improve sleep, cognition, fragile bones, cholesterol levels, high blood pressure, and obesity, as well as decrease vulnerability to diabetes, heart disease, and cancer. That is an awful lot to ask of a daily bout of physical activity.

However, many studies over the past several decades have confirmed the positive relationship between exercise and an array of health effects. Exercise is not going to prevent anyone from eventually exiting this world, but engaging in physical activity may make us more healthy while we are still in it.

Studies over the past decade on exercise and mental disorders have added another benefit to consistent physical activity: Depressed patients may benefit as much from routine exercise as they do by taking antidepressants. Craft and Perna published an extensive review of studies on whether or not exercise might have a therapeutic role in clinical depression. The ability of depressed patients to carry out physical work has been shown to be significantly impaired, and they are less fit than the general population, according to some studies cited in the article. It is not hard to find reasons for the diminished physical well-being. Depression is often accompanied by fatigue, social withdrawal, sleep disturbances, and the side effects of antidepressants include dizziness, nausea, and even weight gain. These factors may make engaging in routine physical activity difficult, unless there is outside support to do so.

In a typical study to see whether exercise might be beneficial not just in improving physical status but also in relieving the symptom of depression, the patients are enrolled in an exercise program, walking three or four times a week, for example, or doing resistance training. The severity of their depression is compared with a control group of patients who do not exercise but engage in some other type of intervention so they receive the same amount of care and attention from the research staff. The results have been consistent study after study: Exercise has a positive effect on depression.

In one particularly compelling study, the effect of exercise over 16 weeks was compared with the effect of an antidepressant (sertraline) alone and with sertraline and exercise. About two-thirds of the patients in each group went into remission after the four-month testing period. The results indicate that exercise alone was as effective as the medication alone or medication plus exercise in relieving the depression.

If exercise is treated like any other therapeutic intervention, it is important to determine the most effective dose, timing, and type, as one would with medication. Walking slowly on a treadmill versus jogging or resistance training once a week, or four times a week, are some of the variables that have to be examined. Should the exercise be mild or intense? Is it better to exercise outside in the fresh air and sunlight, or does this make any difference? Might yoga or other group exercise be more beneficial than solitary workouts, or a walk, because they diminish social isolation? Is there some way of identifying patients at the onset of their depression who might benefit from exercise rather than antidepressant therapy? How long should it take for an exercise program to produce a lessening of depressive symptoms? Many antidepressants take several weeks before they seem to have an effect; should the patient wait the same amount of time to see whether exercise relieves symptoms?

These questions can be answered fairly easily with additional studies. What is more difficult is how to translate these findings to the real world. To begin with, who is going to treat the patients? Therapists are rarely, if ever, also trained as exercise physiologists. And exercise physiologists may not have any training or experience working with depressed clients. Do these professionals even communicate with each other? A therapist may be able to refer a patient to a physical therapist for an initial consultation as to what kind of exercise the patient can do without injury or pain, but how should the patient follow up? Where will she exercise? Does he have to join a gym or a local Y to exercise? Who will determine the type of exercise program? What oversight is available to make sure the exercise program is carried out effectively and without injury or pain from overused muscles? Who will help/motivate the depressed patient to participate over several weeks rather than dropping out? And finally, even if exercise can be as effective as medication for depression, who will pay for it? Visits to a psychotherapist and medication may be paid for now in their entirety, or at least in part, by health insurance. Therapeutic visits with an exercise physiologist rather than a prescription for an antidepressant is probably not covered under billing codes for mental illness, and thus may be an out-of-pocket expense.

And yet, exercise should not be overlooked or discarded as an effective way of managing depression. Its value in increasing general health, sleep efficacy, and increased physical fitness, in addition to relieving the symptoms of depression without the side effects of drugs, cannot be overestimated. Now is the time to figure out how to apply this knowledge.

References

“The Benefits of Exercise for the Clinically Depressed,” Craft L and Perna F, Prim Care Companion J Clin Psychiatry. 2004; 6(3): 104–111.

“Effects of exercise training on older patients with major depression,” Blumenthal JA, Babyak MA, and Moore KA. et al. Arch Intern Med. 1999 159:2349–2356

The Social Isolation of a Painful Disease

We visited B for the first time in three years because of our infrequent trips to the country in which she lives, thousands of miles and several time zones away from us. Emails and phone calls had informed us of her worsening fibromyalgia, but we were not prepared for the almost total isolation imposed by her chronic pain. She has trouble walking because of pain in her legs, and simple movements, such as getting up from a chair or climbing a flight of stairs, are difficult or on some days impossible. Plans to socialize with friends or attend a lecture at the university where she used to be a professor are often canceled, she told us, due to overwhelming fatigue.

Fibromyalgia is a disease that seemed to defy diagnosis or categorization for decades, because no objective measurements, such as blood tests or scans, revealed the source of the symptoms. An advertisement for a drug to relieve the pain of fibromyalgia demonstrates the hidden nature of the disease: A woman tells us that we might assume she is perfectly healthy, because there are no outward signs of her symptoms, yet she is in constant pain.

Fortunately, the medical community has now accepted fibromyalgia as a real disease with multiple symptoms. The most common is pain that seems to migrate almost randomly around the body, affecting soft tissue, tendons, ligaments, and muscle. However, patients may experience severe migraines, sleep disturbances, mood and cognitive disorders, gastrointestinal disturbances, and fatigue.

It is not clear what causes the disease or why pain is felt when there is no visible injury, inflammation, infection, or sign of any other cause, such as cancer. Now researchers are investigating whether the pain is not due to some injury or other disorder within the body, but rather to inappropriate messages from centers in the brain that signal the presence of pain.

One therapeutic approach has been the use of drugs which activate neurotransmitters such as serotonin and norepinephrine to see if they can counteract the pain signals from the brain. But the drugs are not always effective and have their own side effects. Presently, a multifaceted therapeutic approach is advised, incorporating psychological counseling, cognitive-behavioral therapy, meditation, exercise, and reducing sleep disturbances.

However, these interventions are not always successful. Our friend swam and did exercises in the water for two years with no improvement. Now an exercise physiologist trained to work with fibromyalgia patients is available to help her exercise twice a week, but the sessions are often canceled because the intensity of her pain makes any type of exercise too difficult.

Physicians and other health professionals have not been able to find any effective intervention to allow this once-vibrant woman to return to her former active life. She taught university-level courses, turned her research into highly regarded books, and was active in an organization that worked with disadvantaged children. Now, most of her days are spent alone in her apartment with a part-time caretaker. Her friends have dropped away, not because they don’t want to be with her, but because her pain makes it difficult for her to be social. Her hands hurt too much to text or email or engage in social media, and she finds it hard to carry on phone conversations. We don’t know how much our visit cost her in pain. Because we had traveled so far to see her, she never revealed to us, honestly, how she was feeling.

And yet it was apparent that having visitors who made a point of not focusing the entire conversation on her disease had a positive effect. We amused her with some interesting gossip, engaged her in a political discussion that we knew would animate her, shared memories of a time when we lived in the same city, and talked about her research.

Did her pain recede as a result? We never asked, but the energy she summoned several minutes into our visit seemed to indicate that perhaps her pain was not taking over her life at that time.

Sadly, we had to leave her and return home, promising not to wait so long before we made the trip again. But our visit pointed out how a chronically painful disease reduces the quality of life and in particular the loss of human contact. And it is not obvious what can be done. It is hard to spend time with someone who is in constant pain; we don’t know what to say, how to help, or how to understand what they are feeling unless we have had similar experiences. We fear that we may be causing the patient more stress by forcing her to put on a cheerful face and chitchat with us as if nothing is wrong when we all know that she is deeply distressed. Sometimes it’s easier to stay away.

But we shouldn’t stay away. We should not allow the pain and other symptoms, such as sleep disturbances, limit our visits with the patient. If we allow this to happen, then we are allowing the disease to replace our relationships.

When we saw our friend, it was apparent that once we stopped talking about her disease and switched to topics that have consumed our mutual interests for decades, she seemed to focus less on her pain and more on engaging with us in discussing the interests we had shared for many years. Indeed, at some point, we all forgot about the fibromyalgia and simply remembered how good it was to be with each other.

Perhaps social contact should be added to the top of the long list of interventions for this disease. Pain may be present, whether the patient is alone or with others. But when others are around, good conversations, laughter, stories, arguments, etc., may prove an invaluable distraction from the pain. It may not always work; pain may cause social interactions to be delayed or canceled. But it is important to try, because the rewards of seeing a friend or family member relieved of chronic pain, even temporarily, are immense.

References

Goldenberg DL. Fibromyalgia syndrome. An emerging but controversial condition. JAMA 1987; 257:2782.

Björkegren K, Wallander MA, Johansson S, Svärdsudd K. General symptom reporting in female fibromyalgia patients and referents: a population-based case-referent study. BMC Public Health 2009; 9:402.

Clauw DJ. Fibromyalgia: A clinical review. JAMA 2014; 311:1547.

When Bone Soup Promises More Than It Delivers

One of my neighbors was recently diagnosed with liver and pancreatic cancer. She is rapidly losing weight because eating and digesting food causes her pain, but her weight loss may make recovery from chemotherapy more difficult. She told me she is drinking bone broth in order to obtain the nutrients she needs, and to halt her weight loss.

Why? I asked her when we talked today.Everyone says it is good for me,” she answered, everyone upon further questioning being some relatives and a few friends. “But you need nourishment, I protested. You need to eat protein, you need carbohydrates for energy, and you need vitamins and minerals. You aren’t going to stop losing weight by drinking bone-flavored water.“

Fortunately, her oncologist referred her to a hospital dietician experienced in the nutritional needs of cancer patients such as my friend, and the bone broth is now watering some house plants. But this incident is an example of how popular food fads, health food supplements and neighborly advice may exacerbate, rather than solve nutritional problems.

Bone broth, a soup containing mostly water and the flavor and some nutrients from the bones cooked in it, is a broth that people have been eating for eons. It is, in some respects, like drinking liquid, salty Jell-O. When beef bones are cooked for long periods of time, they turn into a gelatinous mass, as I discovered when I forgot about a pot of water and bones I was simmering in order to make stock for soup. (Washing the pot became a major endeavor.) This gelatin in the hands of competent cooks can be turned into aspic, a translucent covering for pates and cold chicken, or a sweet “Jell-O” type dessert. Proponents of bone broth point to the gelatin as evidence of its vast nutritional value: all the good protein and the collagen from the bones is going to decrease inflammation, fortify your bones, and lubricate your joints. What is not mentioned is that gelatin is an incomplete protein because it lacks the essential amino acid tryptophan, and contains very small amounts of another amino acid, tyrosine.

Both tryptophan and tyrosine are needed for the synthesis of new protein in our bodies. Thus, if my friend depends on the gelatin in bone broth in order to make new protein for her muscles that are wasting away, she will be unable to do so. Moreover, the collagen in bone broth is digested in the intestinal tract, and is no more able to lubricate our joints than the butter or oil we may be eating.

Ironically, if a chicken were simmered along with the bones it would turn into (drum roll please) chicken soup. The chicken is a good source of protein, and although the power of chicken soup to heal the body may be exaggerated, its ability to soothe the distress of a bad cold or flu, or maybe restore the body after a bout of chemotherapy does not seem to be in dispute.

It is disconcerting to find bone broth sold in supermarkets and online for not inconsiderable amounts of money. In the old days, before this fad, people threw a few bones in a pot of water and whatever vegetables they had to make a very cheap soup. Bones also used to be given to dog owners or sold in enormous quantities to be turned into gelatin, or the fertilizer bone meal. Paying $10.00 or more for a box of bone broth containing mostly water seems absurd.

What is so worrisome about this food fad, and the many others that pop up like mushrooms after a wet spell, is that they suggest we don’t have to rely on food for our daily nourishment or to compensate for some nutritional deficit such as lack of vitamin C or iron. The health food store, not healthy foods at the grocery store, is promoted as the path to nutritional wellness. I receive updates from several online newsletters describing the latest supplement entering the health food market. It is often astonishing to read about the promises made, without any evidence, for these products. One of many entering the market this past month includes bitter melon, cinnamon bark, fenugreek seed, olive leaf and artichoke leaf, holy basil herb and lycium fruit. These are presented in a liquid and supposedly will maintain normal blood sugar levels in people with normal blood sugar levels (italics are my own). Apparently the makers of this supplement never heard of insulin that our pancreas secrete (for free) when we eat carbohydrates. Another product also just now for sale is made from Siberian rhubarb roots and promises to help menopausal symptoms like hot flushes. The research supporting these claims and many others is often not real or reproducible, but how would a consumer know this? 

My friend with cancer believed that the bone broth she was drinking, even though her weight was melting off, was nourishing her. Unfortunately, she was getting none of the nutrients she needed. People may hesitate to seek medical advice or ignore it completely because they are convinced that the promises made by the supplements will be the answer to their medical problems. Supplements can interfere with drugs one is already taking. Given the number of supplements on the market, and the sometimes bizarre source of ingredients (who knew that rhubarb could be grown in Siberia?), physicians may not know whether the ingredients are dangerous. Plus the dose of a supplement may be entirely too high. For example, many doses of melatonin range from 3 mg to 10 mg; the dose established by clinical research puts the dose at 0.3-0.5 mg and the higher dose may dampen the body’s own melatonin production.

The FDA has information about the ingredients, function and side effects of many supplements, and it is worth spending time learning about a supplement that has been recommended or advertised before taking it. Some are critically important, such as those providing the vitamins and minerals an individual may not be able to obtain through food. My friend does take a vitamin-mineral supplement because she finds it too painful to eat many fruits and vegetables.

Our health is too important to be left to the sellers of health products. Checking out the scientific validity of a product may not be possible without the help of dieticians or others knowledgeable about the contents and claims of these products. But it is worth making the time to do so.